Juan Nicolas Pena Sanchez Rein Lepnurm Silvia Bermedo
Transcription
Juan Nicolas Pena Sanchez Rein Lepnurm Silvia Bermedo
Juan‐Nicolas Pena‐Sanchez Juan Nicolas Pena Sanchez [email protected] Rein Lepnurm Rein Lepnurm [email protected] Silvia Bermedo‐Carrasco Silvia Bermedo Carrasco [email protected] 2013 CAHSPR Conference Vancouver BC Canada Vancouver, BC, Canada May 28th, 2013 Latent gender inequalities in the well‐being of physicians according to payment methods 1. Background • Well‐being of physicians • Payment methods for physicians 2. Research objectives 3. Methods • Objectives • Design and sample • Measures • Statistical method i i l h d 4. Results 5. Research limitations and implications 6. 6 Conclusions “That physician will hardly be thought very careful of the health of his patients if he neglects his own” Galen 130–200 A.D. Latent ggender inequalities in th he well‐beingg of physicians Outline 1. Background: well‐being of physicians practicing medicine1, 2. 3 Emotionally‐charged environment 2‐3 : • • • • Suffering Fear Death Sexuality 3 Time pressure and erosion of autonomy have been associated with dissatisfaction of physicians33‐55. associated with dissatisfaction of physicians 3 This is an issue relevant for physicians AND for quality of care l f . 1. 2. 3. 4. 5. McCue JD. The effects of stress on physicians and their medical practice. N Engl J Med. 1982;306(8):458‐63. Wallace JE et al. Physician wellness: a missing quality indicator. Lancet. 2009;374(9702):1714‐21 Williams E, Skinner A. Outcomes of physician job satisfaction. Health Care Manage Rev. 2003;28(2):119‐40. Keeton K et al. of physician career satisfaction, work‐life balance, and burnout. Obstet Gynecol. 2007;109:949‐55. Stoddard J, et al. Managed care, professional autonomy, and income: effects on physician career satisfaction. J Gen Intern Med. 2001 Oct;16(10):675‐84. Latent ggender inequalities in th he well‐beingg of physicians 3 Physicians face intrinsic and unalterable tensions of 1. Background: well‐being of physicians A poor well‐being among physicians could lead to: • • • • • 9 Dissatisfaction of physicians influences quality of health services and the relationships with patients6‐8 • • 1. 2. 3. 4. 5. 6. 7. 8. Distress1 Inequity of efforts and rewards2 3 Leave direct patient care p Burn‐out4 Leaving the medicine5 Related to patient dissatisfaction Associated with lower compliance with treatments Latent ggender inequalities in th he well‐beingg of physicians 9 Lepnurm R et al.. A measure of daily distress in practising medicine. Can J Psychiatry 2009;54:170‐80. Dobson R et al. Developing a scale for measuring professional equity among Canadian physicians. Soc Sci Med 2005;61:263‐6. Hann M et al. Relationships between job satisfaction, intentions to leave family practice and actually leaving among family physicians in England. Eur J Public Health 2011;21:499‐503. Escribà‐Agüir V, et al. [Effect of psychosocial work environment and job satisfaction on burnout syndrome among specialist physicians]. Gac Sanit 2008;22:300‐8. Lanndon B et al. Leaving medicine: the consequences of physician dissatisfaction. Med Care 2006;44:234‐42. Williams E, Skinner A. Outcomes of physician job satisfaction. Health Care Manage Rev. 2003;28(2):119‐40. Keeton K et al. Predictors of physician career satisfaction, work‐life balance, and burnout. Obstet Gynecol. 2007;109:949‐55. Carlsen F, Bringedal B. [Population satisfaction with health care and physician job satisfaction]. Tidsskr Nor Laegeforen. 2009 Feb;129(5):405‐7. 1. Background: well‐being of physicians increased considerably increased considerably1. 3 Conflicts between work and home play significant roles in burnout, and the significant roles in burnout and the predictors of burnout differ by gender2. 3 A considerable percentage of physicians who are mothers report A id bl f h i i h h high levels of work‐to‐family conflicts3. 3 There is evidence that female specialists are paid slightly less in comparison to male physicians 4. 3 New cohorts of female physicians tend to choose alternative payment Latent ggender inequalities in th he well‐beingg of physicians 3 The proportion of female physicians has methods rather than the traditional schemes5. 1. 2. 3. 4. 5. Canadian Institute for Health Information (CIHI). Supply, Distribution and Migration of Canadian Physicians, 2010 [Internet]. CIHI 2011 Langballe EM, et al. The predictive value of individual factors, work‐related factors, and work‐home interaction on burnout in female and male physicians. Stress and Health. 2011; 27: 73‐87. Wallace JE, Lemaire J. On physician wellbeing‐you'll get by with a little help from your friends. Soc Sci Med. 2007; 64: 2565‐77. Leigh JP, et al. Physician wages across specialties: informing the physician reimbursement debate. Arch Intern Med. 2010; 170: 1728‐34. Canadian Institute for Health Information (CIHI). Profiling Physicians by Payment Program: A Closer Look at Three Provinces [Internet]. CIHI 2010. 1. Background: payment methods for physicians t t l h lth total health expenditures: dit * Latent ggender inequalities in th he well‐beingg of physicians 3 Payment of physicians is the third‐largest category of Figure based on CIHI data: National Health Expenditure Trends, 1975 to 2011. Ottawa: 2011. Available on: https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC1671 1. Background: payment methods for physicians Cost driver contributions to physician expenditure Canada, from 1998 to 2008 • 6.8% was the average annual growth in physician spending • Key drivers were Key drivers were 3 Traditionally physicians have been paid for services provided through Fee‐For p g 2, 3 Service(FFS) 3 All provinces and territories have p implemented Alternative Payment Plans (APP)3,4: • • • • 1. 2. 3. 4. Salaries Capitation Sessional contracts Blended plans Source: CIHI. Health Care Cost Drivers: The Facts (2011) ,Pg 20. CIHI. Health Care Cost Drivers: The Facts. Ottawa: 2011. Available on: https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC1672 CHSRF. Myth: Most physicians prefer fee‐for‐service payments. Mythbusters Teaching Resource . 2010 CIHI. Canadian Institute for Health Information. Physicians in Canada: The Status of Alternative Payment Programs, 2005–2006. Ottawa: 2008. Wranik DW, Durier‐Copp M. Physician remuneration methods for family physicians in Canada. Health Care Anal. 2010;18(1):35‐59. Latent ggender inequalities in th he well‐beingg of physicians 3 Health care cost drivers (1998 to 2008)1: 1. Background: payment methods for physicians 3 Diverse forms of APPs have been implemented across , Canada. Canada 1, 2 3 APPs have been increasing from 10.6% in 2000 to 26.8% in APPs have been increasing from 10.6% in 2000 to 26.8% in 2010.1 3 Concerns regarding declining physician productivity1 3 Shift to APP may have variable effects on physician Shift to APP may have variable effects on physician behaviours and clinical practice patterns3 1. 2. 3. CIHI. Canadian Institute for Health Information. Physicians National Database, Payments and Utilization, Wranik DW, Durier‐Copp M. Physician remuneration methods for family physicians in Canada. Health Care Anal. 2010;18(1):35‐59. Elit L, Cosby J. Does shifting a physician payment system shift physician priorities? Eur J Gynaecol Oncol. 2006;27(4):375‐8. Latent ggender inequalities in th he well‐beingg of physicians Alternative Payment Plans (APPs) 2. Research objectives To identify differences in the levels of career satisfaction, fulfilment‐recognition d d d il di f h i i b rewards, and daily distress of physicians by gender and payment method To assess interactions between gender and payment method on the three measures of physicians’ well‐being. h i i ’ ll b i Latent ggender inequalities in th he well‐beingg of physicians Objectives 3. Methods: design and sample from July to December 2011 from July to December 2011 3 Inclusion criterion: • Physicians practicing in the SHR 3 Exclusion criteria: E l i i i • MDs in a residence program • On leave of absence or retired 3 A survey sent by mail and with an on‐line option offered by e‐mail li i ff d b il 3 Ethics and Operational Approval Ethics and Operational Approval Latent ggender inequalities in th he well‐beingg of physicians 3 Cross‐sectional study conducted 794 physicians were eligible 3. Methods: measures (professional equity) Balance between contributions and rewards2,3: – – 3 3 Tangible rewards Intangible rewards A 15‐item scale developed and validated in 2004, cross‐national study in Canada3 My Outcomes (Salary, promotions, bonuses, etc.) Others’ Inputs (education, experience, etc.) Others’ Outcomes (Salary, promotions, bonuses, etc.) Dimensions3: • • • 1. 2. 3. My Inputs (education, experience, etc.) Fulfilment Financial Recognition Adams’ Equity Theory2 Effort‐reward imbalance at work: Theory, measurement and evidence” by Department of Medical Sociology, Duesseldorf University, Pg 3 Borkowsky N. Process theories of Motivation. In: Organizational behavior, theory, and design in health care, Pg 132 Dobson R, Lepnurm R, Struening E. Developing a scale for measuring professional equity among Canadian physicians. Soc Sci Med. 2005 Jul;61(2):263‐6. Latent ggender inequalities in th he well‐beingg of physicians 3 3. Methods: measures (career satisfaction) Professional equity and career satisfaction are complementary 3 Integrates four dimensions of career satisfaction1‐2 3 Assesses the higher order needs of physicians2 3 The 16‐item scale developed and validated in a cross‐national study1 Inherent and performance high‐order needs Personal and Professional low‐order needs Latent ggender inequalities in th he well‐beingg of physicians 3 1. Lepnurm R, Danielson D, Dobson R, Keegan D. Cornerstones of career satisfaction in medicine. Can J Psychiatry. 2006 Jul;51(8):512‐22. 2. Gerrity M, et al. Career satisfaction and clinician‐educators. The Society of General Internal Medicine Career Satisfaction Study Group. J Gen Intern Med. 1997 Apr;12 Suppl 2:S90‐7. 3. Methods: measures (daily distress) 9 Measures distress of physicians identifying1‐2: Job strain at lower levels of distress 1 2 Never A few times yearly 3 4 Once 2‐3 times monthly monthly 5 6 7 Once weekly 2‐3 times weekly Daily Risk of burnout at higher levels g of distress 9 16‐item scale with sub‐scales of fatigue and negative affect1 9 Instrument validated across Canada in 20041 1. 2. Dobson R, Lepnurm R, Struening E. Developing a scale for measuring professional equity among Canadian physicians. Soc Sci Med. 2005;61(2):263‐6. Dobson R, Lepnurm R. Wellness activities address inequities. Social Science & Medicine. 2000;50(1):107‐21. Latent ggender inequalities in th he well‐beingg of physicians 9 Related to everyday issues faced by physicians1 4. Results 37.2% 48.1% 794 Eligible physicians 382 Participated 9 Bias was checked and found negligible. 9 Broad specialty categories: • Family Practitioners/GPs • Medical specialists • Surgical specialties • Laboratory /Medical images 35.6% 31.4% 25.9% 7.1% 62.6% Latent ggender inequalities in th he well‐beingg of physicians Response rate espo se ate 4. Results The MANOVA test (Wilks’ Lambda criterion) identified that the Lambda criterion) identified that the 3 The MANOVA test (Wilks dependent variables: • Affected by gender, p=0.04 Affected by gender p=0 04 • Not by the payment method, p=0.41 • There was no evidence of an interaction effect, p=0.3 Latent ggender inequalities in th he well‐beingg of physicians 3 The three dependent variables were correlated (p<0.001): 4. Results 3 Female physicians reported: • Lower levels of career satisfaction, Lower levels of career satisfaction, p p=0.01 0.01 • Lower levels of fulfilment‐recognition rewards, p=0.01 • Higher levels of daily distress, p=0.03 Latent ggender inequalities in th he well‐beingg of physicians 3 The three dependent variables were correlated (p<0.001): 4. Results recognition equity: • An interaction effect was identified between gender and payment method and payment method F(2,375)=3.51, p=0.03. Latent ggender inequalities in th he well‐beingg of physicians 3 In the levels of fulfilment‐ 5. Research limitations • Relationships are associations • Sequence of events cannot be determined 3 Results can be extrapolated to: • All the physicians in the SHR p y • Practitioners in similar health regions (Regina Qu'Appelle Health Region), with caution 3 Response rate is adequate in comparison to other surveys among physicians. 3 Response bias was checked. Latent ggender inequalities in th he well‐beingg of physicians 3 Inherent limitations of cross‐sectional studies 5. Research implications 3 Gender inequalities need to be considered when designing payment methods for physicians. 3 The findings suggest that APP do not threaten physicians’ clinical y autonomy. 3 Female physicians report: • Higher percentage of complex patients1 • Less control on daily aspects of practice2 Extra challenges to achieve work‐life balance3‐4 • Extra challenges to achieve work‐life balance and professional development4‐5 1. 2. 3. 4. 5. McMurray JE, et al. The work lives of women physicians. J Gen Intern Med.2000; 15: 372‐80. Brown S, Gunderman RB. Viewpoint: enhancing the professional fulfillment of physicians. Acad Med. 2006; 81: 577‐82 Verlander G. Female physicians: balancing career and family. Acad Psychiatry. 2004; 28: 331‐6. Shollen SL, et al. Organizational climate and family life: how these factors affect the status of women faculty at one medical school. Acad Med. 2009; 84: 87‐94 Leigh JP, et al. Physician wages across specialties: informing the physician reimbursement debate. Arch Intern Med. 2010; 170: 1728‐34 Latent ggender inequalities in th he well‐beingg of physicians 3 Strategies to eliminate gender inequalities are still required. 6. Conclusions and professional equity, and higher levels of daily distress. 3 Latent gender inequalities in the well‐being of physicians need to L t t d i liti i th ll b i f h i i dt be addressed. 3 APP and blended payment methods did not show differences in the well‐being indicators. 3 Potential interaction effects of payment method and gender need to be explored in national studies. Latent ggender inequalities in th he well‐beingg of physicians 3 Female physicians reported poorer levels of career satisfaction Acknowledgements 9 MERCURi Research Group • 9 Medical Affairs Office , SHR • • • 9 Advisory Committee: • • • • • Dr. Allen Backman Dr. Rein Lepnurm Dr. Roy T. Dobson Dr. David Keegan Dr. David Keegan Dr. Joseph Garcea Debora Voigts M Margaret Lissel t Li l Stan Yu John Dickinson 9 WRTC Training Program 9 George & Arlene Loewen George & Arlene Loewen Family Bursary Family Bursary 9 University of Saskatchewan Travel Award 9 Professors School of Public Health, U of S 9 2013 CASHPR Travel Student Bursary MERCURi Research Group Latent ggender inequalities in th he well‐beingg of physicians 9 Physicians of the Saskatoon Health Region Latent ggender inequalities in th he well‐beingg of physicians Publication available Publication available By Juan Nicolás Peña Sánchez